Source · Prevention of Future Deaths
Peter Frosdick
Ref: 2019-0423
Date: 12 Dec 2019
Coroner: Yvonne Blake
Area: Norfolk
Responses identified: 0 / 1
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Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care as his condition didn't fit service criteria. Teams lacked awareness of referral criteria and dismissed GP insights, hindering appropriate treatment.
Date
12 Dec 2019
56-day deadline
24 Feb 2020 est.
Responses identified
0 of 1
Coroner's concerns
Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care as his condition didn't fit service criteria. Teams lacked awareness of referral criteria and dismissed GP insights, hindering appropriate treatment.
View full coroner's concerns
During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.
(1) That no-one appeared to have looked at mental health except to note that he was alcohol dependant: This was an escalating presentation from someone who had no previous contact with the services_ his
(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team_ home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't: (3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol.
(1) That no-one appeared to have looked at mental health except to note that he was alcohol dependant: This was an escalating presentation from someone who had no previous contact with the services_ his
(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team_ home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't: (3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol.
Report sections
Investigation and inquest
On 7 June 2019 | commenced an investigation into the death of Peter Frosdick aged 48 years_ The investigation concluded at the end of the inquest on 28 November 2019.The conclusion of the inquest was cause of death 1a) Hanging and that whilst Mr Frosdick took his own life, he was unable to form the necessary intent due to his state of mind,
Circumstances of the death
Mr Frosdick chronically abused alcohol. In 2018 he had blood tests and then a CT scan which showed cirrhosis of the liver. He was advised that he should stop drinking alcohol He became convinced that he was going to die of liver failure. This was not the case. Had he been told this 6 months earlier he would have been able to stop drinking and be saved. This was an irrational view as he was not in liver failure. He was referred to the Mental Health Team/Crisis ResolutionWellbeing; none of which accepted him for treatment as it was felt that his major problem was alcohol misuse: He was displaying paranoid thinking; was showing extreme anxiety and irrational behaviour: He hung himself in his garage
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
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Report details
- Reference
- 2019-0423
- Date of report
- 12 December 2019
- Coroner
- Yvonne Blake
- Coroner area
- Norfolk
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Feb 2020 (estimated).
Sent to
- Norfolk & Suffolk NHS Trust